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The nurse teaches a patient about pursed lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed? The patient practices by blowing through a straw. The patient's ratio of inhalation to exhalation is 1:3. The patient inhales slowly through the nose. The patient puffs up the cheeks while exhaling. - ✔✔ 4 A 55-year-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary function testing (PFT) for this condition, what is the most important question the nurse should ask? "Do you have any metal implants or prostheses?" "Have you taken any bronchodilators in the past 6 hours?" "Are you claustrophobic?" "Are you allergic to shellfish?" - ✔✔ 2 A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? Ciprofloxacin (Cipro) 400 mg IV
Acetaminophen (Tylenol) rectal suppository Chest x-ray via stretcher Blood cultures from two sites - ✔✔ 4 A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy. Which instruction should the nurse include in the discharge teaching? Oxygen flow should be increased if the patient has more dyspnea. Oxygen use can improve the patient's prognosis and quality of life. Storage of oxygen tanks will require adequate space in the home. Travel opportunities will be limited because of the use of oxygen. - ✔✔ 2 A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) White blood cell (WBC) count: 72,000/mm Prothrombin time: 35 seconds Serum sodium: 130 mEq/L Blood urea nitrogen (BUN): 19 mg/dL
Arrange for a friend to administer the medication on schedule. Give the patient written instructions about how to take the medications. - ✔✔ 2 A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? "Surgery is the treatment of choice for stage I lung cancer." "Tell me what you know about the various treatments available." "Are you afraid that the surgery will be very painful?" "Did you have bad experiences with previous surgeries?" - ✔✔ 2 A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) Drainage of 75 mL/hr Tracheal deviation Production of pink sputum Pain at insertion site Sudden onset of shortness of breath - ✔✔2,
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis - ✔✔ 3 After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? Schedule the patient for directly observed therapy three times weekly. Discuss with the health care provider the need for the patient to use an injectable antibiotic. Teach about treatment for drug-resistant TB treatment. Ask the patient whether medications have been taken as directed. - ✔✔ 4 The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the oxygen saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider. - ✔✔abdc
pursed-lip breathing Kussmaul's respirations accessory muscle use increased AP diameter - ✔✔Tripod position and Accessory muscle use The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the health care provider? Lung expansion is decreased bilaterally. Hyperresonance to percussion is present. Respirations are 36 breaths/minute. Anterior-posterior chest ratio is 1:1. - ✔✔ 3 Which information will the nurse include in the asthma teaching plan for a patient being discharged? Hold your breath for 5 seconds after using the bronchodilator inhaler. Tremors are an expected side effect of rapidly acting bronchodilators. Use the inhaled corticosteroid when shortness of breath occurs.
Inhale slowly and deeply when using the dry powder inhaler (DPI). - ✔✔ 2 Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? Notify the health care provider immediately about any bloody or foul-smelling sputum. Teach about the need for prolonged antibiotic therapy after discharge from the hospital. Teach the patient to avoid the use of over-the-counter expectorants. Assist the patient with chest physiotherapy and postural drainage. - ✔✔ 2 The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? "I can use my nasal decongestant spray until the congestion is all gone." "I will watch for changes in nasal secretions or the sputum that I cough up." "I can take acetaminophen (Tylenol) to treat my discomfort." "I will drink lots of juices and other fluids to stay well hydrated." - ✔✔ 1 When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? Administration of an inhaled bronchodilator
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? Acetaminophen (Tylenol) Piperacillin/tazobactam (Zosyn) Codeine Guaifenesin (Robitussin) - ✔✔ 2 The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy? The patient takes propranolol (Inderal) for hypertension. The patient uses acetaminophen (Tylenol) for headaches. The patient has chronic inflammatory bowel disease. The patient has a history of pneumonia 6 months ago. - ✔✔ 1 The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage. - ✔✔abdc
A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? Tying a square knot at the back of the neck Using half-strength peroxide for cleansing Holding the device securely when changing ties Suctioning the client first if secretions are present - ✔✔ 1 Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? Respiratory rate of 28 breaths/minute Resting pulse oximetry (SpO2) of 85% Weak, nonproductive cough effort Large amounts of greenish sputum - ✔✔ 3 A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by the nurse is most appropriate? Place on bed rest for at least 4 hours after bronchoscopy. Notify the health care provider about blood-tinged mucus.
Place the client in high-Fowler's position and apply oxygen. Contact the provider and prepare for intubation. Reassure the client that the voice change is temporary. Document the finding and assess the client hourly. - ✔✔ 2 A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) Facilitating pleural fluid sampling Assisting with chest tube insertion Providing antipyretics as needed Performing frequent respiratory assessment Suctioning deeply every 4 hours - ✔✔a.Assisting with chest tube insertion b.Facilitating pleural fluid sampling c.Performing frequent respiratory assessment d.Providing antipyretics as needed When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? Discuss the need to rinse the mouth out after using any inhalers.
Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs). Teach the patient about the use of expectorants. Use a swab to obtain a sample for a rapid strep antigen test. - ✔✔ 4 A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? A 68-year-old who has dependent edema and clubbed fingers A 74-year-old with a chronic cough and thick, tenacious secretions A 46-year-old with a 30-pack-year history of smoking A 52-year-old in a tripod position using accessory muscles to breathe - ✔✔ 4 After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? Bilateral nose swelling and bruising Inability to breathe through the nose Clear nasal drainage Complaint of nasal pain - ✔✔ 3
Blood pressure (BP) is less than 140/90 mm Hg. Patient reports decreased exertional dyspnea. - ✔✔ 4 When assessing a patient's sleep-rest pattern related to respiratory health, what should the nurse ask the patient (select all that apply)? Do you need to sleep with the head of the bed elevated? Do you wake abruptly or gasping for air throughout the night? Do you fall asleep throughout the day? Do you sleep more than 8 hours per night? Do you wake often throughout the night to urinate? Do you find yourself waking with a headache or often developing an early am headache? - ✔✔? I did choose them all and got credit The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night or needing to urinate during the night is not indicative of impaired respiratory health. A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching? Self-administration of inhaled corticosteroids Complications associated with oxygen therapy
Use of long-acting b-adrenergic medications Side effects of sustained-release theophylline - ✔✔ 1 A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate? Deficient knowledge related to lack of education about COPD Chronic low self-esteem related to increased physical dependence Complicated grieving related to expectation of death Ineffective coping related to unknown outcome of illness - ✔✔ 2 An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? Assist the patient to deep breathe, cough, and use the incentive spirometer. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine. Milk the chest tube gently to remove any clots. Clamp the chest tube momentarily to check for the origin of the air leak. - ✔✔ANS: 2 The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.
The patient's history indicates a 30 pack-year cigarette history. - ✔✔ 1 Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? Teach the patient about self-care of the tracheostomy. Determine the need for replacement of the tracheostomy tube. Assess the patient's risk for aspiration. Suction the tracheostomy when needed. - ✔✔ 4 The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? The patient's respirations are shallow. The patient's respiratory rate is 32 breaths/minute. The patient's PaO2 is 45 mm Hg. The patient's PaCO2 is 33 mm Hg. - ✔✔ 3 Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care? Perform percussion before assisting the patient to the drainage position.
Give the ordered albuterol (Proventil) before the patient receives the therapy. Schedule the procedure 1 hour after the patient eats. Maintain the patient in the lateral position for 20 minutes. - ✔✔ 2 The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? Use of accessory muscles in breathing Peak expiratory flow rate of 240 L/minute Pulse oximetry reading of 91% Respiratory rate of 26 breaths/minute - ✔✔ 1 The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? Remind the patient about the importance of taking medications. Visit the patient daily to administer the prescribed medications. Use a marked pillbox to set up the patient's medications. Discuss the option of moving to an assisted living facility. - ✔✔ 3
